Updated Aug 2019

At last, SSS has issued a form for an Affidavit of Undertaking for SSS members who cannot get a Certificate of Separation and Non-advancement of SSS Maternity Benefit from their employers due to certain reasons like being AWOL.

woman employee documents-sss affidavit


This is how the Affidavit of Undertaking appears:


SIC - 01247 (12-2015)

Republic of the Philippines          )
City/Municipality of __________) S.S.
Province of _________________)


                               AFFIDAVIT OF UNDERTAKING

                               (Sickness/Maternity Benefit Claim)


            I, _____________________________________________, of legal age,
      _______________ citizen, single/married, with address at
      ___________________________________________________________ ,
      after having been sworn in accordance with law, hereby depose and state, that:

      1.  I, _______________________ is a member of the Social Security System
           (SSS) with SS Number/Common Reference Number _________________;

      2.  I was an employee of ______________________________, with business
           address at ___________________________________________  __, from
           _________________________and was separated on _______________;

      3.  That I cannot secure a certificate of separation and non-advance payment
           of my sickness/maternity benefit due to the reason/s stated below:
           [ ] The company is on strike.
           [ ] I have a pending labor case with the company.
           [ ] Company has ceased operation.  
           [ ] I was separated from the company due to Absence Without Official
                Leave (AWOL).
           [ ] With strained relations with my employer.
           [ ] Others (Please specify) _____________________________________

      4.   In case it is proven that I have given false information, I undertake to return
            or to be deducted from future benefits due me in full the amount I have received
           from the SSS;

      5.  I am aware that I may be criminally liable for any false statement or representation
           made in this document or for any other documents submitted in connection with
           my claim, and

      6.  I am executing this affidavit to attest to the truthfulness, veracity and due execution
           of the foregoing statements and this document.  

          Affiant further sayeth naught.


          __________________,        ___________________________________________
               (Date)                                                        (Place)


                                                       __________________________________
                                                                              AFFIANT
                                                             (Signature over Printed Name)


     SUBSCRIBED AND SWORN to me this ____________day of ____________ 20___,

affiant exhibiting to me his/her Community Tax Certificate No. ______________
issued on _______________ at _________________ and Identification Card with No.
_______________________issued by __________________ on ___________________
valid until _____________________.


                                                                                                   Notary Public

Doc. No. ______________
Page No. ______________
Book No. ______________
Series of 20 __________

Download here the SSS Affidavit of Undertaking (English)

                                           SSS Affidavit of Undertaking (Tagalog) 


Photo credit: Photo by Gabrielle Henderson on Unsplash